Recertification Application Form 2006 For Recertification By by zcc46658


                                                                                                                        NO FAXES ACCEPTED
                                                                                                                         NO STAPLES PLEASE


EXAM DATE: Saturday, April 1, 2006 (candidates choosing to recertify by exam)
APPLICATION DEADLINE DATE: Friday, December 2, 2005
  (All applications must be postmarked on or before above dates)
COMPLETING THIS FORM IS MANDATORY FOR ALL CANDIDATES. All information will be kept confidential.

                                                                                 Specialty Nursing Code: ____ ____
    Recertification by Continuous Learning or by Exam
    Recertification option (   check one):
                                                                              Critical Care (adult)   CC            Occupational Health     OH
       Recertification by Continuous Learning                                       Cardiovascular    CV                       Oncology     OC
       Recertification by Exam                                                          Emergency     ER                    Perioperative   OR
                                                                                      Gerontology     GR       Psychiatric/Mental Health    MH
                                                                                       Nephrology     NP                        Perinatal   PR
    CNA Certification #: ___ ___ ___ ___ ___ ___ ___ ___                             Neuroscience     NN

IDENTIFICATION INFORMATION                                                                                 (SEE APPLICATION GUIDE PAGE 9)

Language of correspondence preferred:   English      French
PLEASE PRINT LEGIBLY! All information must be accurate to avoid delays. (Indicate your name as you wish it to appear on your certificate.)



CITY                                                                         PROVINCE                         POSTAL CODE

(        )                                                                   (         )
HOME PHONE NUMBER                                                            WORK PHONE NUMBER                                PHONE EXTENSION

E-MAIL ADDRESS 1                                                             E-MAIL ADDRESS 2

REGISTRATION AND/OR MEMBERSHIP IN CNA                                                                 (SEE APPLICATION GUIDE PAGES 10-11)

Check ( ) one: I am a:         CNA member         non-member of CNA (Please refer to pages 10-11 of the application guide for membership details.)
ALL CANDIDATES: Attach photocopy of your current (2005) provincial/territorial nursing registration licence.
ONTARIO NURSES NOTE: In order to receive the CNA member fee, you must also attach a photocopy of your current (2005-2006)
                        Registered Nurses Association of Ontario (RNAO) membership.

    CUT OUT AND ATTACH HERE                                                      CUT OUT AND ATTACH HERE
     COPY OF CURRENT (2005)                                                       COPY OF CURRENT (2005)
    REGISTERED NURSE LICENCE                                                      MEMBERSHIP WITH RNAO
      (If lost, please contact your association to               I have applied for my 2006 RNAO membership but have not received it yet.
                      obtain a copy.)                            I will send a copy of my membership card upon receipt [Fax: 613 237-6684].

                                        ANY MISSING INFORMATION WILL INCUR DELAYS                                                                1
    RECERTIFICATION ELIGIBILITY CRITERIA                                                                            (SEE APPLICATION GUIDE PAGES 2-3)

    Please indicate under which option you are applying.                 Option 1           Option 2

   VERIFICATION OF NURSING SPECIALTY EXPERIENCE                                                                 (SEE APPLICATION GUIDE PAGES 11-12)

                          EMPLOYER                               POSITION                              SUPERVISOR/                       DATES OF                     HOURS
                                                                                                       CONSULTANT                       EMPLOYMENT                   (During previous
                                                                                                                                                                       5 years only)
             FULL NAME OF EMPLOYER / HOSPITAL            TITLE                                       NAME

                                                                                                                                                FROM MM/YY             Hrs/year

                                                         RESPONSIBILITIES                            TITLE                                        TO MM/YY
                                                                                                                                                                     Total # hours


             POSTAL CODE

             FULL NAME OF EMPLOYER / HOSPITAL            TITLE                                       NAME

                                                                                                                                                FROM MM/YY             Hrs/year


                                                         RESPONSIBILITIES                            TITLE                                        TO MM/YY
                                                                                                                                                                     Total # hours


             POSTAL CODE

             FULL NAME OF EMPLOYER / HOSPITAL            TITLE                                       NAME

                                                                                                                                                FROM MM/YY             Hrs/year

                                                         RESPONSIBILITIES                            TITLE                                        TO MM/YY
                                                                                                                                                                     Total # hours


             POSTAL CODE

* Use a separate sheet if necessary to include more than         TOTAL CALCULATED HOURS to meet eligibility criteria:                                                   0
  THREE (3) previous relevant experiences.

  NOTE: List previous 5 years of nursing specialty experience only. All other information is not applicable. One full-time year = 1,950 hrs
  Application deadline date is December 2, 2005, but if necessary, you can calculate your hours up to the end of your certification term.

    CONTINUOUS LEARNING ACTIVITIES                                                                                       (SEE APPLICATION GUIDE PAGE 12)

  ITEM                    CONTINUOUS LEARNING ACTIVITY               NAME OF SPONSOR / PROVIDER                     DATE                NO. OF HOURS                  OFFICE
 NUMBER                                                                    OR INSTITUTION                     (previous 5 years only)   (excluding breaks & meals)   USE ONLY
                                                                                                                                                                     YES     NO
                                                                                                                                                                     YES     NO
                                                                                                                                                                     YES     NO
                                                                                                     TOTAL HOURS                                   0
    Total required CL hours = 100 hours.
    You may use this form, the Continuous Learning Activities form, or your own list (e.g., electronic file), in a similar format, but you must
    provide total hours here.

                    CL APPROVAL BY REVIEWER           Candidate meets CL criteria:      Y        N

                    Total CL hours approved: _______________________________ Signature of reviewer: ________________________________ Date ________________

                    NURSING PRACTICE                POST BASIC                          EDUCATION
                                 Y                         Y             01      Diploma              04     Doctorate                           Exam Dev. (CTPW)
                                 N                         N             02      Baccalaureate        05     Other
                                 V                                       03      Master’s

    2                                             ANY MISSING INFORMATION WILL INCUR DELAYS
SUPERVISOR/CONSULTANT IN THE SPECIALTY                                                                               (SEE APPLICATION GUIDE PAGE 13)

I verify that ________________________________________ has been actively involved in the delivery of direct nursing care to patients or in the
                                (candidate’s name)

management, teaching or research of ______________________________ nursing. I further document that this candidate also meets the minimum
                                                         (nursing specialty)

number of nursing experience hours for CNA Certification in the nursing specialty, as indicated by the candidate on this application form. (Briefly

describe the candidate’s ability to apply specialized knowledge and skills in the nursing specialty.)

SIGNATURE OF SUPERVISOR/CONSULTANT                                              EMPLOYER                                         DATE
                                                                                (     )

NAME (PLEASE PRINT)                                                             WORK PHONE #

POSITION/TITLE                                                                  E-MAIL ADDRESS
NOTE: The CNA Certification Program reserves the right to verify the employment, licensure or registration of any applicant.

NURSING EDUCATION HISTORY                                                                                            (SEE APPLICATION GUIDE PAGE 13)

1. Please check ( ) the highest level of NURSING education completed.
       Diploma         Baccalaureate       Master’s     Doctorate
                                                                                                 School/University                      Year

2. Please check ( ) if applicable:      Yes, I have POST-BASIC education in my nursing specialty (e.g., community college course in nursing specialty).

STATEMENT OF UNDERSTANDING                                                                                           (SEE APPLICATION GUIDE PAGE 13)

For your application to be processed, please sign and date this form.
I hereby apply for recertification by continuous learning or by exam offered by the Canadian Nurses Association (CNA) and understand that
certification depends on successfully completing specified program requirements. To this end, I authorize CNA to make whatever inquiries
may be deemed necessary to verify my credentials and professional standing.
I understand there is a non-refundable portion of the application fee for all candidates who apply for CNA Certification.
Information collected by CNA through the certification process may be used for statistical, policy, research and promotional purposes.
This information is used in a non-identifiable form. I agree that my data can be included as described in this paragraph pursuant to
CNA’s policy on privacy and information available on CNA’s website.
To the best of my knowledge, the information on this application is complete and accurate.

X                                    Candidate’s Signature                                                                     Date

    Y      N Do you agree to CNA releasing your name, address and certification status to the national association for your specialty to
              enable the association to contact you?
If your contact information changes, it is your responsibility to notify CNA’s Certification Program directly. Please note you must contact
BOTH the CNA Certification Program and the circulation department as their databases are separate.

                                              ANY MISSING INFORMATION WILL INCUR DELAYS                                                               3
 WRITING CENTRE INFORMATION                                                                                                                      (SEE APPLICATION GUIDE PAGES 14-15)

 Language of exam preferred (YOU MUST CHOOSE ONE):                                English                                                 French

 Writing Centre Code: ___ ___ ___ ___ ___ City Name: _______________________________________ (see application guide page 14)
 If you require the following, you must use the Writing Centre Special Request Form available on request by calling
 1-800-450-5206. This form must be completed and sent at the time of application.
 • A special exam accommodation (If you have a disability that prohibits you from taking the exam under standard conditions) – Please enter SPAC
   on the preceding Writing Centre Code line.
 • A substitute writing center (If you live a minimum of 200 km from any of the 50 advertised writing centres listed) – Please enter SBWC on the
   preceding Writing Centre Code line – an administrative fee of $75 + GST/HST is charged per candidate for setting up a substitute writing center
 • An alternate exam date (If religious or other reasons prohibit you from taking the exam on a Saturday, a special exam date of Friday, March 31, 2006
   may be requested.) – Please enter ALWD on the preceding Writing Centre Code line.

 PAYMENT INFORMATION                                                                                                                                    (SEE APPLICATION GUIDE PAGE 16)

General Information                                                                                                           Name of person or organization paying, if other than candidate
                                                                                                                              (A receipt will be issued in this person’s name.)
• Choose one payment method. If paying by credit card, complete and
  return the Credit Card Payment form included in the application guide.                                                      __________________________________________________
• Make cheques payable to the Canadian Nurses Association.                                                                     Recertification Fees
• This is the only certification fee you will pay during your five-year term.                                                  For recertification by continuous learning
• The fees include the price of the CNA Certification prep guide, which                                                            CNA Members (GST – $262.15)                          _______________
                                                                                    All fees include the administration fee
  will be sent automatically to all eligible candidates writing the exam.                                                          CNA Members (HST – $281.75)                          _______________

• Incorrect payment of fees will DELAY the processing of your                                                                      Non-Members of CNA (GST – $326.35)                   _______________
  application.                                                                                                                     Non-Members of CNA (HST – $350.75)                   _______________

                                                                                                                               For recertification by exam
NOTE regarding refunds:                                                                                                            CNA Members (GST – $454.75)                          _______________
                                                                                                                                   CNA Members (HST – $488.75)                          _______________
• There is a non-refundable $53.50 (incl. GST) or $57.50 (incl. HST) appli-
                                                                                                                                   Non-Members of CNA (GST – $642)                      _______________
 cation fee for all candidates who apply for CNA Certification (candi-
                                                                                                                                   Non-Members of CNA (HST – $690)                      _______________
 dates found inelegible will receive a refund).
                                                                                                                                   Rewrite (GST – $321) (all unsuccessful candidates)   _______________
• There is an administrative fee of $21.40 (incl. GST) or $23.00 (incl. HST)                                                       Rewrite (HST – $345) (all unsuccessful candidates)   _______________
 for non-approved payments (cheque or credit card).
                                                                                                                                   Substitute writing centre fee (GST – $80.25)         _______________
• Fee deducted from refund for withdrawal PRIOR to receipt of the prep                                                             Substitute writing centre fee (HST – $86.25)         _______________
 guide $53.50 (incl. GST) or $57.50 (incl. HST).                                                                               HST FEES APPLY TO RESIDENTS OF NL, NB, NS.                   $0.00
                                                                                                                               GST FEES APPLY TO RESIDENTS OF:
• Fee deducted from refund for withdrawal AFTER receipt of the prep                                                              BC, AB, SK, MB, ON, QC, PE, NU, NT, YT
                                                                                                                                                                                         TOTAL FEES
  guide $85.60 (incl. GST) or $92.00 (incl. HST).
• Fee deducted from refund for late withdrawal within 30 days prior to                                                         Payment Methods
  exam $107.00 (incl. GST) or $115.00 (incl. HST) (in addition to the                                                             Cheque (One cheque for full payment is enclosed.)
  preceding listed fee).
                                                                                                                                  Credit card (Complete the attached credit card payment form.)
• There is a duplicate receipt fee of $10.70 (incl. GST) or $11.50 (incl. HST).                                                   Money Order (One money order for full payment is enclosed.)

 OFFICE USE ONLY                                                  AUDIT STATUS                                                      N                         A             P             R
                                                                  REGISTRATION                                                      Y
  Received ___________________________________                    ENDORSEMENT                                                       Y
                                                                  C.L.                                                              Y                                              Date & Initials
  Pre-reviewed ________________________________
  Reviewed ___________________________________                                                                                               ELIGIBILITY              E ____________________
                                                                                                                                                                      C ____________________
  Data-entry _________________________________
                                                                                                                                                                      I ____________________
  Audit _____________________________________

                     1400 Blair Place, Suite 210, Ottawa ON K1J 9B8 • 1-800-450-5206 • •

 4                                           ANY MISSING INFORMATION WILL INCUR DELAYS
                            DEMOGRAPHIC INFORMATION
                                                            CANADIAN NURSES ASSOCIATION CERTIFICATION PROGRAM
                                        The demographic information collected on this form is to be used for statistical analysis and policy development.
                                                                                                   This information is used in a non-identifiable form.
   Please indicate the applicable information in the box(es) on the left.

(two-letter code)
                    1. Certification or recertification specialty:
                       CV   Cardiovascular                          GR    Gerontology                                   OT   Orthopaedics
                       CM   Community Health                        PC    Hospice Palliative Care                       PR   Perinatal
                       CC   Critical Care – Adult                   NP    Nephrology                                    OR   Perioperative
                       CP   Critical Care Pediatrics                NN    Neuroscience                                  MH   Psychiatric/Mental Health
                       ER   Emergency                               OH    Occupational Health                           RH   Rehabilitation
                       GI   Gastroenterology                        OC    Oncology

                    2.Year of application

                    3. Type of application:
(I or R)               I Initial certification
                       R Recertification

                    4. Province or territory of nursing registration:
                       AB          MB         NL            NT            ON         QC           YT
                       BC          NB         NS            NU            PE         SK

                    5. Highest level of nursing education:
                       01 Diploma                                    02   Baccalaureate                      03 Master’s
(01-05)                04 Doctorate                                  05   Other __________________________________________________

                    6. Gender:
(F or M)              F Female
                      M Male

                    7. Place of employment:
                       01   Community Health Centre                  02   Hospital                       03 Nursing Education Setting
                       04   Occupational Health Setting              05   Nursing Home/Special Care      06 Physician’s Office/Family Practice
                       07   Public Health Setting                    08   Rehabilitation Centre          09 Self-Employed/Independent Practice
                       10   Visiting/Home Care Agency                11   Other: _____________________________________

                    8. Position:
                       01   Assistant/Associate Dean               02 Clinical Nurse Specialist             03 Consultant
                       04   Director/Vice-president Nursing        05 Instructor/Professor                  06 Nurse Manager
                       08   Researcher                             09 Staff Nurse                           10 Supervisor/Co-ordinator
                       11   Licensed Registered Nurse Practitioner 14 Working in the Role of a Nurse Practitioner
                       12   Other: _____________________________________________________________________________________
            9. Total years experience as a registered nurse:
               01 1-2 years                              02    3-5 years                               03 6-10 years
  (01-06)      04 11-20 years                            05    21-30 years                             06 30+ years

            10. Total years experience in your certification specialty area:
               01 1-2 years                              02    3-5 years                               03 6-10 years
               04 11-20 years                            05    21-30 years                             06 30+ years

            11. Area(s) of responsibility:
               02   Cardiovascular                03 Emergency                          04 Gerontology
               06   Perinatal                     07 Medical/Surgical                   08 Nephrology
               09   Neuroscience                  10 Occupational Health                11 Perioperative
               12   Oncology                      13 Pediatrics                         14 Psychiatric/Mental Health
               15   Public/Community Health       16 Visiting Home Care                 19 Critical Care Adult
               20   Critical Care Pediatric       21 Gastroenterology                   22 Orthopaedic
               23   Rehabilitation                24 Hospice Palliative Care            25 Enterostomal/ Wound Care
               17   Other: ______________________________________________________________________

            12. How did you find out about the CNA Certification Program? (check [ ] all that apply)
               01      Brochure                           02     Journal Ad                     03    Friend/Colleague
  (01-09)      04      Poster                             05     Provincial Association         06    Specialty Organization
               07      Other (e.g., recertification): ________________________________________________________________
               08      Conference                         09     CNA Website

            Thank you for taking the time to complete this form.                                                        2005

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